Every finding on record at Haven Nursing Center

Based on record review, observations, and interviews the facility failed to ensure that a resident receive treatment and care in accordance with professional standards of practice by failing to identify a wound for 1 (#33) of 3 residents reviewed for non-pressure related skin conditions.Findings: Review of Resident #33's medical record revealed diagnoses which included chronic systolic congestive heart failure, unilateral primary osteoarthritis (right hip), atherosclerotic heart disease of native coronary artery without angina pectoris, old myocardial infarction, unspecified protein-calorie malnutrition, and major depressive disorder.Review of the annual MDS assessment dated [DATE] for Resident #33 revealed a BIMS score of 7 which indicated severe cognitive impairment. Further review revealed she required substantial-maximal assistance with most ADLs. Resident #33 was assessed to be at moderate risk for pressure ulcers and had no current pressure ulcers and no other skin problems identified.An interview with Resident #33's family member on 06/08/2026 at 9:40 a.m. revealed the resident had an area on her bottom that she did not think they were treating.During a head to toe physical assessment of Resident #33's skin with S5LPN, observation revealed a small scabbed area was noted on her right upper buttock. S5LPN confirmed she was not aware of the scabbed area on her right upper buttock.Observation of Resident #33's skin with S2DON and S3ADON on 06/09/2026 at 1:40 p.m. confirmed there was a small scabbed area to her right upper buttock. They reported no staff had informed them of the above area and were not aware of the wound.An interview with S6CNA on 06/09/2026 at 1:48 p.m. revealed she worked with Resident #33 on 06/05/2026 and she saw an abrasion on her right upper buttock. S6CNA revealed she reported the area to the resident's nurse (she was unsure of her name).Review of the Weekly Skin Assessments from 05/07/2026 to 06/04/2026 revealed there was no documentation Resident #33 had any skin conditions or wounds.Review of Wound assessment dated [DATE] for Resident #33 revealed the following: right gluteus; other skin issue - scab; new wound, acquired in-house; 1.39 cm length x 1.22 cm width; and no sign or symptom of infection; no odors, pain, undermining, tunneling, or exudate.Interviews with S2DON and S3ADON confirmed the above area to Resident #33's right upper buttock should have been identified timely and reported to S3ADON.

Based on record reviews and interviews, the facility failed to ensure residents were free from unnecessary medications for 1 (#13) of 5 residents reviewed for unnecessary medications. The facility failed to monitor for edema for Resident #13 while on receiving Lasix (diuretic medication).Findings: Review of Resident #13's record revealed an admission date of 04/17/2023 with diagnoses including unspecified dementia without behavioral, psychotic, or mood disturbances, generalized anxiety disorder, and major depressive disorder recurrent.Review of Resident #13's quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Further review of the MDS revealed resident received a diuretic medication. Review of Resident #13's June 2026 Physician's Orders revealed an order dated 09/26/2025 for Lasix oral tablet 20 mg one tablet by mouth one time a day (monitor for edema).Review of Resident #13's May and June 2026 MARs revealed no documented evidence of monitoring for edema while resident was receiving Lasix.Interview on 06/10/2026 at 11:40 a.m. with S3ADON confirmed Resident #13 received Lasix and failed to have documented evidence of monitoring for edema.

Based on record reviews and interviews, the Pharmacist failed to identify and report irregularities to the attending Physician, the facility's Medical Director and DON for 1 (#13) of 5 residents reviewed for unnecessary medications. Findings: Review of Resident #13's record revealed an admission date of 04/17/2023 with diagnoses including unspecified dementia without behavioral, psychotic, or mood disturbances, generalized anxiety disorder, hypertension, chronic obstructive pulmonary disease, and major depressive disorder. Review of Resident #13's June 2026 physician's orders revealed an order dated 02/06/2026 for Abilify (antipsychotic medication) 5 mg oral tablet give 2.5 mg (1/2 tab) by mouth one time a day and an order dated 09/26/2025 for Lasix (diuretic medication) oral tablet 20 mg one tablet by mouth one time a day (monitor for edema).Review of the record revealed Resident #13 did not have an appropriate diagnosis for the use of an antipsychotic medication (Abilify).Review of Resident #13's May and June 2026 MARs revealed the resident was administered a Lasix (diuretic) and an Abilify daily. Further review of the MAR revealed no documented evidence of monitoring for edema while the resident was on Lasix. Interview on 06/10/2026 at 11:40 a.m. with S3ADON revealed the Pharmacist failed to notify the facility of the need for an appropriate diagnosis for the use of Abilify on the pharmacy reviews dated 04/29/2026 and 05/28/2026 for Resident #13. S3ADON confirmed the Pharmacist failed to notify the facility of Resident #13 not having documentation of monitoring for edema while the resident was on Lasix on the pharmacy review on 05/28/2026.

Based on record reviews, and interviews, the facility failed to ensure that licensed nurses have the specific competencies, and skill sets necessary to care for resident needs by not 1) having documentation of a change of condition regarding a resident's low blood pressure and/or low pulse for 1 (#84) of 3 closed records reviewed, and 2) notifying a resident's physician for a high blood sugar reading for 1 (#10) of 1 residents reviewed for insulin.Findings: Resident #84Review of the facility's Charting and Documentation policy and procedure (undated) revealed the following in part:Policy StatementAll services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication the interdisciplinary team regarding the resident's condition and response to care.Policy Interpretation and ImplementationDocumentation in the medical record may be electronic, manual or a combination.The following information is to be documented in the resident medical record:d. changes in the resident's condition.Review of the medical record for Resident #84 revealed an admission date of 07/01/2025.Resident #84 had diagnoses that included dementia, anxiety, diabetes mellitus, heart disease, myocardial infarction, COPD, hyperlipidemia, dysphagia, and muscle weakness. Review of the quarterly MDS assessment dated [DATE] revealed Resident #84 had a BIMS score of 3 which indicated severe cognitive impairment for daily decision making. Review of the vital signs record for Resident #84 revealed the following:On 04/01/2026 at 5:02 p.m. revealed a blood pressure reading of 80/69;04/02/2026 at 11:00 a.m. revealed a blood pressure reading of 130/49 and pulse was 41, and at 4:49 p.m. blood pressure of 95/55 and pulse of 56;04/03/2026 at 8:00 a.m. revealed a blood pressure reading of 70/51; and04/04/2026 at 9:47 a.m. revealed a blood pressure reading of 96/51.Review of the medical record revealed there was no documented evidence of the resident's change of condition regarding Resident #84's low blood pressure and/or low pulse.On 06/10/2026 at 12:45 p.m. interview with S3ADON confirmed there was no documented evidence in the medical record of the resident's change of condition regarding Resident #84's low blood pressure and/or low pulse. Resident #10 Review of the medical record revealed Resident #10 had an admission date of 06/25/2025 with a diagnosis of diabetes.Review of the June 2026 physician orders revealed an order for accuchecks before meals and at bedtime and to notify the physician for accucheck results greater than 400. Review of the June 2026 MAR revealed on the morning of 06/05/2026, Resident #10 had an accucheck result of 517. There was no documentation in the progress notes that the physician was notified of the accucheck results greater than 400. On 06/09/2026 at 2:30 p.m., interview with S3ADON confirmed there was no documentation that the physician was notified of the accucheck result greater than 400.

Based on record reviews and interviews, the facility failed to ensure residents were free of chemical restraints by failing to ensure a resident had an appropriate diagnosis for the use of an antipsychotic medication for 1 (#13) of 5 residents reviewed for unnecessary medication. Findings: Review of Resident #13's record revealed an admission date of 04/17/2023 with diagnoses including unspecified dementia without behavioral, psychotic, or mood disturbances, generalized anxiety disorder, and major depressive disorder recurrent.Review of Resident #13's quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Further review of the MDS revealed resident received antipsychotic medication and diuretic medication. Review of Resident #13's June 2026 Physician's Orders revealed an order dated 02/06/2026 for Abilify (antipsychotic medication) 5 mg oral tablet give 2.5 mg (1/2 tab) by mouth one time a day. Interview on 06/10/2026 at 9:58 a.m. with S3ADON revealed Resident #13 was currently receiving Abilify, which was an antipsychotic medication, and had a diagnosis of unspecified dementia without behavioral disturbances. S3ADON confirmed Resident #13 did not have an appropriate diagnosis for the use of an antipsychotic medication.

Based on observations and interview the facility failed to store, prepare, distribute and serve food under sanitary conditions. The facility failed to 1) ensure food item packages were sealed and not left open to air, 2) document refrigerator and freezer temperatures, and 3) document steam table food temperatures. Findings:On 06/08/2026 at 7:50 a.m. observation of the kitchen revealed one package of garlic bread and french toast were stored in the freezer open to air and not sealed properly. One package of hamburger buns was open to air and not sealed properly. Review of the temperature logs revealed no documented evidence of steam table food temperatures from 06/03/2026 - 06/07/2026. Further review of the logs revealed no documented evidence of refrigerator or freezer temperatures from 06/03/2026 - 06/07/2026. On 06/08/2026 at 8:00 a.m. S4DM confirmed the food item packages were open to air and not sealed properly, and no documentation of the steam table food temperatures, or refrigerator and freezer temperatures from 06/03/2026 - 06/07/2026.

Based on observation and interview, the facility failed to provide an infection prevention and control program designed to provide a safe, sanitary and comfortable environment by failing to ensure biohazardous waste was not accessible to unauthorized personnel. Findings:Observations of the biohazardous waste storage closet on 06/08/2026 at 11:24 a.m. and 06/09/2026 at 11:38 a.m. revealed it was unlocked and the contents were accessible to residents and the public, including several filled sharps containers.On 06/10/2026 at 10:05 a.m., interview with S1Administrator confirmed the biohazard door should remain locked and should not be accessible to residents or the public.

Based on observations, interviews, and record reviews, the facility failed to assess residents for self-administration of medications for 1 (#35) of 1 sampled residents observed for medications available at the bedside. Findings: Review of the medical record for Resident #35 revealed an admission date of 04/10/2025. Resident #35 had diagnoses that included rheumatoid arthritis, hypothyroidism, anxiety, edema, hypertension and depression.Review of the annual MDS assessment dated [DATE] revealed Resident #35 had a BIMS score of 15 which indicated intact cognition for daily decision making.Review of the June 2026 physician orders revealed Resident #35 had a skin tear to the left shin, and an order dated 05/02/2026 to clean with wound cleanser, pat dry, apply Mupirocin ointment, apply non adherent dressing wrap daily and as needed until healed.On 06/08/2026 at 8:35 a.m., and 11:23 a.m. observations of Resident #35's room revealed a tube of Mupirocin ointment on the over bed table.On 06/08/2026 at 11:25 a.m. interview with Resident #35 revealed the nurse left the ointment in the room yesterday. On 06/09/2026 at 1:00 p.m. S3ADON was notified of the Mupirocin ointment in Resident #35's room on the over bed table. S3ADON confirmed Resident #35 should not have medications at the bedside and the resident had not been assessed to self-administer medications.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote healing and prevent the development of new pressure ulcers for 2 (#7, #30) of 5 (#7, #30, #61, #66, #136) residents investigated for pressure ulcers. The deficient practice was evidenced by the facility failing to provide pressure reducing devices for a resident with a stage 3 pressure ulcer (#7) and for a resident who was at a moderate risk for developing pressure ulcers (#30). Findings: Review of the facility Pressure Injury Prevention and Management Policy revised 06/21/2024 revealed the following, in part: Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, and prevent the development of additional pressure ulcers/injuries. 4. Interventions for Prevention and to Promote Healing: c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: iii. Provide appropriate, pressure-redistributing, and support surfaces. Resident #7 Review of the record revealed resident #7 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, type 2 diabetes mellitus with diabetic nephropathy, cerebral infarction, chronic obstructive pulmonary disease, polyneuropathy, unspecified dementia, peripheral vascular disease, congestive heart failure, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 3, which indicated she was severely cognitively impaired. Resident #7 required extensive 2 person assistance for most activities of daily living (ADLs). Further review revealed she was at risk for developing pressures and there was no pressure reducing device for her chair. On 05/06/25 at 8:31 a.m., resident # 7 was observed in her wheelchair in her room. S4Certified Nursing Assistant (CNA) confirmed there was no pressure relieving cushion in the seat of resident #7's wheelchair. On 05/06/2025 at 12:00 p.m., resident #7 was observed in her wheelchair in the dining area and there was no pressure relieving cushion noted in the seat of her wheelchair. Review of resident #7's active physician orders revealed she was receiving treatment for a stage 3 pressure injury to her right posterior thigh and a suspected deep tissue injury to her right heel. Review of resident #7's active care plan revealed the facility had identified she was at a high risk for pressure ulcers with an intervention to follow the facility policies and procedures for the prevention and treatment of skin breakdown. On 05/06/25 at 01:53 p.m., S2Director of Nursing (S2DON) was informed there was no pressure relieving cushion in resident # 7's wheelchair. S2DON confirmed resident #7 should have had a pressure relieving cushion in her wheelchair since she currently had a pressure ulcer to her right posterior thigh. Resident #30 Resident #30 was admitted to the facility on [DATE] with diagnoses that included morbid obesity, reduced mobility, muscle weakness and repeated falls. Review of the most recent MDS assessment dated [DATE] revealed resident #30 had a BIMS score of 13 which indicated she was cognitively intact. Resident #30`s most recent weight was measured on 04/07/2025 and revealed a weight of 311 pounds. Review of the most recent quarterly Braden scale for predicting pressure sore risk assessment dated [DATE] revealed resident #30 had a score of 13. The score of 13 indicated resident #30 was at moderate risk for developing pressure ulcers. On 05/05/2025 at 12:13 p.m., observation and interview revealed resident #30 did not have a cushion for her wheelchair as she was sitting at the dining room table for lunch. Resident #30 reported she sat in the wheelchair most of the day because she could not walk. Resident #30 also reported she would like a cushion in her chair but was never offered a cushion. On 05/06/2025 at 08:21 a.m., resident # 30 was observed in the dining room eating breakfast while sitting in wheelchair. There was no pressure relieving cushion observed in her wheelchair. Resident # 30 confirmed there was no cushion and complained of her wheelchair being uncomfortable. On 05/06/2025 at 01:50 p.m., an interview with S2DON confirmed resident # 30 should have a cushion in her wheelchair to reduce risk for developing a pressure ulcer. 40238

Based on record review and interview the facility failed to have quarterly quality assessment and assurance (QAA) meetings with required members of the QAA committee present. The failed practice was evidenced by the facility`s medical director not being present for the quarterly meetings reviewed. Review of the (QAA) meetings revealed meetings were held on 01/30/2025, 11/12/2024, 07/30/2024, and 03/28/2024. Review of the attendance roster revealed the medical director`s signature was not recorded on the roster. On 05/07/2025 at 02:25 p.m., an interview with S1 Administrator confirmed the medical director was not present for above quarterly QAA meetings.

Based on record review and interview, the facility failed to maintain acceptable parameters of nutritional status by failing to follow up with the physician in a timely manner to implement the registered dietician's (RD) recommendation for 1 (#14) of 4 (#6, #14, #51, #63) residents reviewed for nutrition. Findings: Review of the medical record for resident #14 revealed an admitted [DATE] with diagnoses including muscle wasting and atrophy, muscle weakness, cognitive communication deficit, chronic obstructive pulmonary disease, chronic atrial fibrillation, Alzheimer's disease with late onset, and vitamin deficiency. Review of the record revealed that resident #14 had a weight of 179.0 pounds on 01/07/2025 and a weight of 162.5 pounds on 03/06/2025 showing a weight loss of 16.5 pounds. Review of active May 2025 physician orders revealed that resident #14 was not currently taking an appetite stimulant. Review of the medical records revealed on 04/01/2025 the RD sent a note to the physician with the recommendation for resident #14 to receive an appetite stimulant. On 05/06/2025 at 3:10 p.m., an interview with S2Director of Nursing (DON0 confirmed the facility did not follow up with the physician in a timely manner to implement the RD recommendations.

Based on observation and interviews, the facility failed to ensure drugs were accessible to only authorized personnel by failing to ensure a medication remained locked away when not in use by having a medication stored at a resident's bedside for 1 (#66) of 1 (#66) reviewed for medication storage. Findings: On 05/05/25 8:56a.m., observation in the resident's room revealed there was a fluticasone inhaler on the bedside table of resident #66. Interview with resident #66 confirmed the inhaler belonged to her. Resident #66 reported the nurse left the inhaler at her bedside. On 05/05/2025 at 9:02a.m., interview with S5 Licensed Practical Nurse (LPN) confirmed the inhaler belonged to resident #66 and the inhaler should not have been left in the resident's room. On 05/07/2025, interview with S2Director Of Nursing (DON) confirmed the inhaler should not have been left at the bedside of resident #66.

Based on observations, record review, and interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#73) of 2 (#73, #76) residents reviewed for positioning and mobility. The deficient practice was evidenced by the facility failing to ensure a resident in a geri chair received proper support of her lower extremities. Findings: Review of the record revealed resident #73 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, atherosclerotic heart disease, hypertension, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 2 indicating that resident #73 was severely cognitively impaired. Further review of the MDS revealed she required extensive 2 person assistance with most activities of daily living. Review of resident #73's active care plan revealed the facility identified the resident needed monitoring related to a history of neck surgery with residual stiffness present. Further review revealed resident #73 may use a geri chair as needed due to her above condition. On 05/05/2025 at 9:52 a.m., resident # 73 was observed in a geri chair in the day area. Further observation revealed her feet were dangling with no support to her lower extremities. On 05/06/2025 at 9:11 a.m. and 3:25 p.m., observations revealed resident #73 was in a geri chair in the day area. Further observation revealed her feet were dangling with no support to her lower extremities. On 5/07/2025 at 9:43 a.m., resident # 73 was observed in a geri chair in the day area. Further observation revealed her feet were dangling with no support to her lower extremities. On 05/07/2025 at 2:15 p.m., the surveyor and S4Licensed Practical Nurse (LPN)/Clinical Manager observed resident # 73 in her geri chair in the day area. Further observation revealed her feet were dangling with no support to her lower extremities. S4LPN/Clinical Manager confirmed her legs and feet should be supported when she is up in the geri chair. On 05/07/2025 at 3:00 p.m., S2Director of Nursing was informed that resident #73 was observed in her geri chair multiple times during the survey with her feet dangling with no support to her lower extremities.

Based on observations, record review and interviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (#231) of 1 resident reviewed for dignity. The facility failed to respect resident #231's request for a more textured diet. Findings: Review of the medical record revealed the resident was admitted on [DATE] with diagnoses including dysphagia following cerebral infarction, severe protein - calorie malnutrition, muscle wasting and atrophy, malignant neoplasm of lower right lobe, iron deficiency anemia, and abnormal weight loss. Review of the Admission Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had independent cognitive skills for daily decision making. The resident required set up or clean up assistance with eating. Review of the physician order dated 04/10/2024 revealed the resident's diet was changed from minced and moist to pureed texture. Review of the nurses notes dated 04/20/2024 at 5:47 p.m. revealed the following: ate 50% or less for 2 or more meals in the day, resident accepts supplements, resident complains of having to eat puree. Review of the nurses notes dated 04/21/2024 at 2:29 p.m. revealed the following: ate 50% or less for 2 or more meals in the day, resident refusing to eat the pureed diet prescribed, resident frequently encouraged to eat, given and accepted supplements. Observation of the lunch meal on 04/21/2024 at 12:30 p.m. revealed the resident received a pureed meal. The resident was drinking his health shake. An interview with the resident at this time revealed he did not want a pureed diet. Observation of the breakfast meal on 04/22/2024 at 8:30 a.m. revealed the resident received a pureed meal. An interview with the resident at this time revealed he didn't want his food pureed. An interview with the resident on 04/22/2024 at 1:30 p.m. revealed he makes his own decisions about his medical care. An interview with S3Assistant Director of Nursing (ADON) on 04/22/2024 at 11:28 a.m. confirmed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had independent cognitive skills for daily decision making. S3ADON further confirmed the resident makes his own decisions. An interview with S1Director of Nursing (DON) on 04/23/2024 at 10:50 a.m. confirmed the resident was competent to make his own decisions. S1DON further confirmed the facility should have offered the resident to sign a waiver for him to eat his diet in a texture he desired.

Based on observations, interviews, and record reviews the facility failed to ensure a resident maintained acceptable parameters of nutrition by failing to provide a diabetic nutritional supplement as ordered by the physician for a resident who had a recent significant weight loss for 1 (#27) of 3 (#25, #27, #231) residents reviewed for nutrition. Findings: Record review revealed resident #27 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, atherosclerotic heart disease, hypokalemia, major depressive disorder, need for assistance with personal care, generalized muscle weakness, muscle wasting and atrophy, dysphagia, and cognitive communication deficit. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 3 which indicated resident #27 had severe cognitive impairment. Further review revealed resident #27 was dependent on staff for all activities of daily living that required substantial/maximal assistance. Review of resident #27's April 2024 physician orders revealed an active order for a diabetic house supplement two times a day to increase calorie intake due to significant weight loss. Review of resident #27's weights revealed 10/11/2023 = 140.7 pounds, 11/01/2023 = 120.0 pounds, 01/10/2023 = 113.0 pounds, 03/10/2024 = 111.5 pounds, and 04/10/2024 = 115.0 pounds. Review of the April 2024 Electronic Medication Administration Record (EMAR) revealed no documentation of resident #27 receiving the diabetic house supplement twice daily since it was ordered on 04/04/2024. On 04/22/2024 at 1:20 p.m. an interview with S4LPN (Licensed Practical Nurse) confirmed resident #27 had an order for diabetic house supplement twice a day. S4LPN confirmed she did not administer the diabetic house supplement. On 04/22/2024 at 02:25 p.m. an interview with S3ADON (Assistant Director of Nursing) confirmed resident #27 had order for diabetic house supplement two times a day. S3ADON confirmed resident #27 should have received the diabetic house supplement as ordered.

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medication use for 1 (#74) of 5 (#16, #34, #59, #70, #74) sampled residents reviewed for unnecessary medications. The physician failed to ensure a psychotropic medication (Vistaril) was not ordered to be given as needed for a time period greater than 14 days for resident #74. Findings: Record review revealed resident #74 was admitted to the facility 01/27/2024 with diagnoses that include bipolar disorder, major depressive disorder, primary insomnia, unspecified dementia unspecified severity with mood disturbance, fibromyalgia, other forms of scoliosis lumbar region, long term (current) use of opiate, migraine, and anxiety disorder. Review of active April 2024 Physician Orders revealed an order dated 01/28/2024 for Vistaril 50 milligrams (mg) capsule, give one capsule by mouth every 12 hours as needed (prn) for anxiety. Review of the Pharmaceutical Consultant Report dated 02/18/2024 revealed pharmacist recommended that Vistaril prn psychotropic medication should be limited to 14 days. The consultant pharmacist further recommended the physician to provide specific duration/stop date for Vistaril 50 mg q 12 hours prn anxiety. On 04/22/2024 the physician assistant denied the gradual dose reduction, failed to provide a duration/stop date for Vistaril 50 mg every 12 hours prn anxiety, and failed to provide a rationale to continue the medication. Review of the April 2024 (Electronic Medication Administration Record (EMAR) revealed documentation resident #74 received Vistaril 50 mg on the following dates/times: 04/02/2024 at 1553, 04/03/2024 at 1408, 04/04/2024 at 1333, 04/05/2024 at 1550, 04/06/2024 at 1618, 04/07/2024 at 1512, 04/08/2024 at 1538, 04/09/2024 at 1427, 04/10/2024 at 1510, 04/11/2024 1344, 04/12/2024 at 1346, 04/13/2024 at 1332, 04/14/2024 at 1505, 04/15/2024 at 1520, 04/16/2024 at 1403, 04/17/2024 at 1509, 04/18/2024 at 1526, and 04/22/2024. On 04/23/2024 at 1:50 p.m. an interview with S2DON (Director of Nursing) and S3ADON (Assistant Director of Nursing) confirmed that Vistaril (psychotropic) should not be administered as needed greater than 14 days. S3ADON confirmed the physician assistant continued a prn psychotropic medication past 14 days for resident #74 without a documented end date or a rationale for it to be continued.

Based on record review and interviews the facility failed to ensure that an alleged violation involving physical abuse was reported immediately to the administrator for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse. Findings: A review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating with a revision date 01/09/2023 revealed the following, in part: Policy Statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident's property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by the facilities management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. 2. The administrator, Director of Nursing Services or the individual making the allegation immediately reports his or her suspicions to the following persons or agencies: a. the state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services as applicable (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. immediately is defined as: a. within two hours of an allegation involving abuse or results in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident #1 A review of the medical record for resident #1 revealed she was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia, dementia in other disease classified elsewhere, insomnia, and type 2 diabetes mellitus. A review of the 01/04/2024 Quarterly Minimum Data Set (MDS) assessment revealed resident #1 had a Brief Interview of Mental Status (BIMS) of 3, which indicated she was severely cognitively impaired. On 03/05/2024 at 9:15 a.m. an interview with S6CNA (certified nursing assistant) revealed on 02/12/2024 around 5:10 to 5:15 p.m. she was at the dining room table assisting resident #1 eat dinner meal. S6CNA reported resident #1 had a visitor sitting who was also sitting at the table at this time and was either reading a book or talking on his cell phone. S6CNA reported she asked S5CNA if she could finish feeding resident #1 while she helped another resident. S6CNA reported S5CNA relieved her and help finish feeding resident #1. S6CNA reported after she finished assisting the other resident around 6:00 p.m. she assisted resident #1 to get into her night clothes and into bed. S6CNA reported resident #1 was calm and she did not observe any redness or bruising on her skin while getting her ready for bed. S6CNA reported she checked on resident #1 again before got off work around 7:00 p.m. and she was asleep. S6CNA confirmed she did not witness the visitor physically abuse resident #1. On 03/05/2024 at10:19 a.m. a telephone interview with S4LPN (licensed practical nurse) revealed resident #1 had a visitor during the diner meal on 02/12/2024. S4LPN reported she was at the medication cart passing medication and could not see resident #1 or resident #2 who was also sitting at the table. S4LPN reported she could see the visitor who was also sitting at the table from where she was standing. S4LPN reported that she did hear the visitor tell resident #1 to hush up and eat a few times. S4LPN reported she observed the visitor talking on his cell phone while sitting at the table. S4LPN reported she did see the visitor walking away from the table while still talking on his cell phone as he left the secured unit and she did not see him again. S4LPN reported she overheard resident #1 ask resident #2 if she (resident #2) saw that man hit her (resident #1). S4LPN reported she went and looked at resident #1 and asked her if anyone hit her. S4LPN reported resident #1 did not report anyone hit her and started talking to resident #2. S4LPN reported she assessed resident #1 and she did not have any redness or bruising noted to her face, arms or hands. S4LPN reported resident #1 did not appear to be in any pain or distress at this time. S4LPN reported resident #1 does tend to talk a lot and uses word salads when she talks. S4LPN reported resident #1 is generally confused due to her dementia, and had a history had a history of hallucinating and seeing things that were not there such as people and animals. S4LPN reported resident #1 did not display any behaviors other than her normal demeanor. S4LPN confirmed she never observed the visitor physically abuse resident #1. S4LPN reported the next morning, on 02/13/2024 around 7:30 a.m., she talked to S5CNA and S6CNA about what she heard the evening before, resident #1 asking resident #2 if she saw that man hit her, and asked if they heard or saw anything. S4LPN reported S6CNA reported she did not witness anything. S4LPN reported S5CNA revealed she observed the visitor tell resident #1 to shut up and to eat several times while he was talking on cell phone. S4LPN reported S5LPN revealed she observed the visitor grab resident #1's jaw with his hand forcefully and physically closed her mouth as he told her to shut up and be quiet while at the dinner table. S4LPN reported she went and immediately notified S2DON (director of nursing). S4LPN further reported on 02/13/2024 sometime after lunch the S8Hospice RN (registered nurse), who was visiting with resident #2, asked S4LPN if that woman and man was okay. S4LPN asked S8Hospice RN what she (S8Hospice RN) was talking about. S4LPN revealed S8Hospice RN visited with resident#2 on the evening before (02/12/2024 around 5:40 p.m.) and observed the visitor tell resident #1 to shut up and slapped resident #1 on the hand as the visitor was talking on his phone. S8Hospice RN reported the visitor also slapped resident #1 on the back of the head twice as he walked away from the table while talking on his cell phone. S4LPN confirmed S8Hospice RN did not tell her about what she observed on the evening of 02/12/2024 until 02/13/2024. S4LPN denied witnessing the visitor slap resident #1. S4LPN immediately notified S2DON about the incident that occurred on 02/12/2024 around 5:40 p.m. that witnessed by S8Hospice RN. On 03/05/2024 at12:50 p.m. a telephone interview with S5CNA revealed 02/12/2024 around 5:25 p.m. she was passing dinner trays and S6CNA was assisting resident #1 with eating. S6CNA asked S5CNA if she could finish feeding resident #1 so she (S6CNA) could go assist another resident. S5CNA reported she relieved S6CNA and assisted with feeding resident #1. S5CNA revealed resident #1 had a visitor sitting at the table with her. S5CNA reported resident #2 was also sitting at the table. S5CNA reported the visitor was talking on his cell phone and told resident #1 to be quiet and shut up and to eat many times, but she continued to talk. S5CNA reported she witnessed the visitor reach and physically and forcefully grab resident #1's lower jaw and shut her mouth with his hand and told her to shut up as he continued to talk on his cell phone. S5CNA reported that resident #1 stayed quiet for a few minutes then started talking to resident #2. S5CNA reported she finished feeding resident #1 and got up to go assist another resident. S5CNA reported when she finished assisting the other resident, the visitor had already left the facility. S5CNA reported the next morning, on 02/13/2024 around 7:15 a.m. S4LPN told her and S6CNA that she had overheard resident #1 tell resident #2, did you see that man hit me, the evening before and asked if we had heard or seen anything. S5CNA reported she informed S4LPN that she witnessed the visitor physically and forcefully grab resident #1's lower jaw and shut her mouth, telling her to shut up as he was talking on his cell phone while at the dinner table yesterday evening (02/12/2024). S5CNA denied witnessing the visitor slap resident #1. Surveyor asked S5CNA why she waited until the next day to notify S4LPN of witnessing the visitor physically abuses resident #1. S5CNA revealed she knew it was not a good excuse, but she had not been a CNA for very long. S5CNA reported she did not feel like it was her place to say anything. S5CNA reported she knows now she should have reported what she saw to the nurse immediately. On 03/05/2024 at 11:30 a.m. an interview with S2DON revealed S4LPN came to her office on 02/13/2024 around 7:30 a.m. and informed her of the incident which occurred the prior evening, 02/12/2024 around 5:30 p.m., when S5CNA witnessed the visitor physically and forcefully grab resident#1's lower jaw and shut her mouth with his hand and told her to shut up as he continued to talk on his cell phone. S2DON further reported on 02/13/2024 after lunch S4LPN came to her office and reported S8Hospice RN (Registered Nurse) had just informed her (S4LPN) on the previous evening (02/12/2024 around 5:40 p.m.) she witnessed the visitor slap resident #1 on the hand and also the back of resident#1's head twice. S2DON revealed S8Hospice RN had already left the facility. S2DON revealed she then called S8Hospice RN to investigate the incident between the visitor and resident #1. S8Hospice RN reported on the evening of 02/12/2024 she was visiting with resident #2 who receives hospice services. S8Hospice RN reported resident #2 was sitting at the same table with resident #1 and a visitor. S8Hospice RN reported resident #1 was talking when the visitor received a call on his cell phone. S8Hospice RN reported she witnessed the visitor patted resident #1's hand not like you would do your child, but in a disciplinary manor, and told her to hush up and be quiet. S8Hospice RN reported resident #1 continued to talk and the visitor got up from the table and as he walked away he slapped resident #1 twice in the back of her head with an opened hand as he continued to talk on his cell phone. S8Hospice RN reported the slaps to the back of the head were not like you would do your child, but harder in a disciplinary manor. S2DON revealed she asked S8Hospice RN why she did not immediately inform a staff member of what she witnessed on the evening of 02/12/2024. S2DON revealed S8Hospice RN reported resident #1 was not her patient. S2DON reported she called the Hospice Agency's Administrator and informed her of what had occurred and suggested they provide S8Hospice RN with training on reporting abuse. On 03/05/2024 at 1:09 p.m. a telephone interview with S8Hospice RN revealed she no longer works for the Hospice Agency. Surveyor asked S8Hospice RN what she witnessed on the evening of 02/12/2024 between the visitor and resident #1. S8Hospice RN reported that she was at the facility seeing another resident, but stopped by to check in on resident #2 who had recently had a fall. S8Hospice RN reported resident #2 was sitting at the table with resident #1 and the visitor. S8Hospice RN revealed on 02/12/2024 around 5:40 p.m. resident #1 was talking when the visitor received a call on his cell phone. S8Hospice RN reported she witnessed the visitor patted resident #1's hand not like you would do your child, but in a disciplinary manor, and told her to hush up and be quiet. S8Hospice RN reported resident#1 continued to talk and the visitor got up from the table and as he walked away he slapped resident #1 twice in the back of her head with an opened hand as he continued to talk on his cell phone. S8Hospice RN reported the slaps to the back of the head were not like you would do your child, but harder in a disciplinary manor. S8Hospice RN revealed resident #1 continued to talk to resident #2 as the visitor walked away. S8Hospice RN confirmed she did not tell any staff at the facility what she had witnessed between the visitor and resident #1 until the next day (02/13/2024). S8Hospice RN reported she was at the facility on 02/13/2024 and around 11:00 a.m. she informed S4LPN of what she had witnessed the evening before (02/12/2024) between the visitor and resident #1. On 03/06/2024 at 11:00 a.m. an interview with S2DON confirmed S5CNA should have immediately notified S4LPN, S2DON, and S1Administrator of the physical abuse of resident #1 she witnessed on 02/12/2024 at 5:30 p.m. S2DON further confirmed S8Hospice RN should have immediately notified a staff member of the facility of the physical abuse of resident #1 she witnessed on 02/12/2024 at 5:40 p.m.

Based on record reviews and interviews, the facility failed to protect the resident's right to be free from physical abuse by a visitor for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse. The facility failed to protect resident #1 from physical abuse by a visitor. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: A review of the facility's policy titled, Identifying Types of Abuse with an implementation date of 09/15/2021 revealed the following, in part: Policy Statement As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. Policy Interpretation and Implementation 1. Abuse of any kind is strictly prohibited. 2. Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur. 3. It is understood by the leadership in this facility that preventing abuse requires staff education, training, and support, and a facility-wide culture of compassion and caring. 4. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 5. Abuse toward a resident can occur as: a. resident-to resident abuse; b. staff-to-resident abuse; or c. visitor-to resident abuse. Physical Abuse 1. Physical abuse includes, but is not limited to hitting, slapping, punching or kicking. Resident #1 A review of the medical record for resident #1 revealed an admitted [DATE] with diagnoses which included Alzheimer's dementia, dementia in other disease classified elsewhere, insomnia, and type 2 diabetes mellitus. A review of the 01/04/2024 Quarterly Minimum Data Set (MDS) assessment revealed resident #1 had a Brief Interview of Mental Status (BIMS) of 3, which indicated she was severely, cognitively impaired. A review of the facility's Self-Reported Incident Report, dated 02/13/2024, revealed resident #1 had a visitor around 5:30 p.m. on 02/12/2024, during the evening meal. On 02/12/2024 around 5:30 p.m. S5CNA (certified nursing assistant) witnessed the visitor tell resident #1 to hush, shut up several times while talking on a cell phone. S5CNA witnessed the visitor forcefully grab resident #1's face with his hand to shut her mouth after he had repeatedly asked her to stop talking while he was on a phone conversation. There were no injuries observed at time of incident. On 03/05/2024 at 9:05 a.m. an observation of resident #1 revealed she was lying in a low bed which was located on the secured unit. Bed was in lowest position with 1/4 assist bed rails up x2 and pressure pad call bell within her reach. Screening questions revealed resident #1 was alert and pleasantly confused. Resident #1 was oriented to her name but did not know the date, year, place, or her date of birth. Resident #1 did not recall the incident that had occurred on 02/12/2024. Resident #1 was well kempt and dressed appropriately in a clean night gown. Observations of Resident1's exposed skin (face, neck, lower arms and hands) revealed no bruises or skin tears. On 03/05/2024 at 9:15 a.m. an interview with S6CNA revealed on 02/12/2024 around 5:10 to 5:15 p.m. she was at the dining room table assisting resident #1 eat the dinner meal. S6CNA reported resident #1 had a visitor sitting with her, at the table and was either reading a book or talking on a cell phone. S6CNA reported she asked S5CNA if she could finish feeding resident #1 while she helped another resident. S6CNA reported S5CNA relieved her and helped finish feeding resident #1. S6CNA reported after she finished assisting the other resident around 6:00 p.m. she assisted resident #1 to get into her night clothes and into bed. S6CNA reported resident #1 was calm and she did not observe any redness or bruising on her skin while getting her ready for bed. S6CNA reported she checked on resident #1 again before getting got off work around 7:00 p.m. and she was asleep. S6CNA confirmed she did not witness the visitor physically abuse resident #1. On 03/05/2024 at10:19 a.m. a telephone interview with S4LPN (licensed practical nurse) revealed resident #1 had a visitor during the diner meal on 02/12/2024. S4LPN reported she was at the medication cart passing medication and could not see resident #1 or resident #2 who was also sitting at the table. S4LPN reported she could see the visitor who was also sitting at the table from where she was standing. S4LPN reported that she did hear the visitor tell resident #1 to hush up and to eat a few times. S4LPN reported she observed the visitor talking on a cell phone while sitting at the table. S4LPN reported she did see the visitor walking away from the table while still talking on his cell phone as he left the secured unit and she did not see the visitor again. S4LPN reported she overheard resident #1 ask resident #2 if she (resident #2) saw that man hit her (resident #1). S4LPN reported she went and looked at resident #1 and asked her if anyone hit her. S4LPN reported resident #1 did not report anyone hit her and started talking to resident #2. S4LPN reported she assessed resident #1 and she did not have any redness or bruising noted to her face, arms or hands. S4LPN reported resident #1 did not appear to be in any pain or distress at the time of her assessment. S4LPN reported resident #1 does tend to talk a lot and uses word salads when she talks. S4LPN reported resident #1 is generally confused due to her dementia, and had a history of hallucinating and seeing things that were not there, such as people and animals. S4LPN reported resident #1 did not display any behaviors other than her normal demeanor. S4LPN confirmed she never observed the visitor physically abuse resident #1. S4LPN reported the next morning, 02/13/2024 around 7:30 a.m., she talked to S5CNA and S6CNA about what she heard the evening before regarding resident #1 asking resident #2 if she saw that man hit her. S4LPN asked the CNAs if they heard or saw anything. S4LPN reported S6CNA reported she did not witness anything. S4LPN reported S5CNA revealed she observed the visitor tell resident #1 to shut up and to eat several times while he was talking on a cell phone. S4LPN reported S5CNA revealed she observed the visitor grab resident #1's jaw with his hand forcefully and physically closed her mouth as he told her to shut up and be quiet while at the dinner table. S4LPN reported she went and immediately notified S2DON (director of nursing) of the incident involving resident #1 and the visitor. S4LPN further reported on 02/13/2024 sometime after lunch S8Hospice RN (registered nurse), who was visiting with resident #2, asked S4LPN if that woman and man was okay. S4LPN asked the S8Hospice RN what she (S8Hospice RN) was talking about. S4LPN revealed S8Hospice RN visited with resident#2 on the evening before (02/12/2024 around 5:40 p.m.) and observed the visitor tell resident #1 to shut up and slapped resident #1 on the hand as the visitor was talking on his phone. S8Hospice RN reported the visitor also slapped resident #1 on the back of the head twice as he walked away from the table while talking on his cell phone. S4LPN confirmed S8Hospice RN did not tell her about what she observed on the evening of 02/12/2024 until 02/13/2024. S4LPN immediately notified S2DON about the incident that occurred on 02/12/2024 around 5:40 p.m. witnessed by S8Hospice RN. On 03/05/2024 at 12:50 p.m. a telephone interview with S5CNA revealed 02/12/2024 around 5:25 p.m. she was passing dinner trays and S6CNA was assisting resident #1 with eating. S6CNA asked S5CNA if she could finish feeding resident #1 so she (S6CNA) could go assist another resident. S5CNA reported she relieved S6CNA and assisted with feeding resident #1. S5CNA revealed resident #1 had a visitor sitting at the table with her. S5CNA reported resident #2 was also sitting at the table. S5CNA reported the visitor was talking on a cell phone and told resident #1 to be quiet and shut up and to eat many times, but she continued to talk. S5CNA reported she witnessed the visitor reach and forcefully grab resident #1's lower jaw and shut her mouth with his hand and told her to shut up as he continued to talk on his cell phone. S5CNA reported that resident #1 stayed quiet for a few minutes then started talking to resident #2. S5CNA reported she finished feeding resident #1 and got up to go assist another resident. S5CNA reported when she finished assisting the other resident, the visitor had already left the facility. S5CNA reported the next morning on 02/13/2024 at around 7:15 a.m., S4LPN told S5CNA and S6CNA that she had overheard resident #1 tell resident #2, did you see that man hit me the evening before, and S4LPN asked if we had heard or seen anything. S5CNA reported she informed S4LPN that she witnessed the visitor physically and forcefully grab resident #1's lower jaw and shut her mouth telling her to shut up as he was talking on a cell phone while at the dinner table yesterday evening. The surveyor asked S5CNA why she waited until the next day to notify S4LPN of witnessing the visitor physically abuse resident #1. S5CNA revealed she knew it was not a good excuse, but she had not been a CNA for very long. S5CNA reported she did not feel like it was her place to say anything. S5CNA reported that she received counselling from S2DON on 02/13/2024 and in-service training on abuse neglect and reporting. S5CNA reported she knows now she should have reported what she saw to the nurse immediately. On 03/05/2024 at 11:30 a.m. an interview with S2DON revealed S4LPN came to her office on 02/13/2024 around 7:30 a.m. and informed her of the incident which occurred the prior evening, 02/12/2024 around 5:30 p.m., when S5CNA witnessed the visitor physically and forcefully grab resident #1's lower jaw and shut her mouth with his hand and telling her to shut up as he continued to talk on a cell phone. S2DON reported that she immediately called and notified S1Administrator. S2DON reported she assessed resident #1 and the resident did not recall the incident and denied anyone harming her. Resident #1 did not have any bruises or signs or symptoms of pain. S2DON reported resident #1 was normally confused and tended to hallucinate. S2DON reported she notified resident #1's physician of the incident. S2DON revealed S1Administrator and S7Facility Owner contacted the [NAME] and informed him of the incident. S2DON reported S1Admininstrator and S7Facility Owner met with resident #1's family member and informed the family member of the incident. The family member was made aware of the visitor no longer being able to come back to the facility pending the outcome of the investigation. S2DON reported on 02/13/2024 after lunch S4LPN came to her office and reported S8Hospice RN (Registered Nurse) had just informed her (S4LPN) on the previous evening (02/12/2024 around 5:40 p.m.) she witnessed the visitor slap resident #1 on the hand and also the back of resident#1's head twice. S2DON revealed S8Hospice RN had already left the facility. S2DON revealed she then called S8Hospice RN to investigate the incident between the visitor and resident #1. S8Hospice RN reported on the evening of 02/12/2024 she was visiting with resident #2 who receives hospice services. S8Hospice RN reported resident #2 was sitting at the same table with resident #1 and a visitor. S8Hospice RN reported resident #1 was talking when the visitor received a call on his cell phone. S8Hospice RN reported she witnessed the visitor patted resident #1's hand not like you would do your child, but in a disciplinary manor, and told her to hush up and be quiet. S8Hospice RN reported resident #1 continued to talk and the visitor got up from the table and as he walked away he slapped resident #1 twice in the back of her head with an opened hand as he continued to talk on his cell phone. S8Hospice RN reported the slaps to the back of the head were not like you would do your child, but harder in a disciplinary manor. S2DON revealed she asked S8Hospice RN why she did not immediately inform a staff member of what she witnessed on the evening of 02/12/2024. S2DON revealed S8Hospice RN reported resident #1 was not her patient. S2DON reported she called the Hospice Agency's Administrator and informed her of what had occurred and suggested they provide S8Hospice RN with training on reporting abuse. S2DON reported she notified S1Admininstrator and resident #1's physician of the incident. S2DON reported S1Admininstrator called and informed resident #1 family member of the incident. On 03/05/2024 at 1:09 p.m. a telephone interview with S8Hospice RN revealed she no longer works for the Hospice Agency. Surveyor asked S8Hospice RN what she witnessed on the evening of 02/12/2024 between the visitor and resident #1. S8Hospice RN reported that she was at the facility seeing another resident, but stopped by to check in on resident #2 who had recently had a fall. S8Hospice RN reported resident #2 was sitting at the table with resident #1 and the visitor. S8 Hospice RN revealed on 02/12/2024 around 5:40 p.m. resident #1 was talking when the visitor received a call on his cell phone. S8Hospice RN reported she witnessed the visitor patted resident #1's hand not like you would do your child, but in a disciplinary manor, and told her to hush up and be quiet. S8Hospice RN reported resident#1 continued to talk and visitor got up from the table and as he walked away he slapped resident #1 twice in the back of her head with an opened hand as he continued to talk on his cell phone. S8Hospice RN reported the slaps to the back of the head were not like you would do your child, but harder in a disciplinary manor. S8Hospice RN revealed resident #1 continued to talk to resident #2 as the visitor walked away. S8Hospice RN confirmed she did not tell any staff at the facility what she had witnessed between the visitor and resident #1 until the next day (02/13/2024). S8Hospice RN reported she was at the facility on 02/13/2024 and around 11:00 a.m. she informed S4LPN of what she had witnessed the evening before (02/12/2024) between the visitor and resident #1. S2DON reported she submitted the Self-Reported Incident Report to the State Agency within 2 hours of finding out about the allegation of resident abuse. S2DON interviewed S4LPN, S5CNA, and S6CNA and had them write statements. S2DON reported she personally counselled S5CNA on abuse and reporting. S2DON reported the facility has no video surveillance cameras. S2DON reported all residents were assessed for abuse on 02/14/2024 by her and S3ADON (Assistant Director of Nursing) and there were no signs of abuse or reports of abuse. S2DON reported S3ADON performed in-service training with all staff on the following: abuse, neglect and reporting, on dementia and also HIPAA (Health Insurance Portability and Accountability Act). S2DON reported they had added the resident abuse to the facilities QAPI (Quality Assurance and Performance Improvement) plan and they developed a Plan of Correction (POC). They determined all resident were vulnerable to abuse. They devised an Abuse and Neglect Interview Form to document resident's assessments. S2DON reported she is keeping a log of all the abuse and neglect assessments and she is monitoring the POC by performing two random assessments the week of 02/19/2023 and 02/26/2024. On 03/06/2024 at 9:45 a.m. an interview with S1Admininstrator and S2DON reported all POC areas were put into place. S1Admininstratorm and S2DON confirmed on 02/29/2024 they had the POC completed and addressed all the training and monitoring. Review of the in-services trainings revealed all staff had completed the following computerized training: Abuse, Neglect, and Exploitation, Abuse and Neglect, Dementia Care: Understanding Communication, and Dementia Care: Challenging Behaviors and Direct Care Staff. Throughout the survey on 02/05/2024 and 02/06/2024, observations, record reviews, and staff interviews revealed they received training on the facility's abuse policies and procedures, Abuse, Neglect, and Exploitation, Abuse and Neglect, Dementia Care: Understanding Communication, and Dementia Care: Challenging Behaviors and Direct Care Staff. Observations and interviews with residents throughout the survey revealed there were no issues regarding resident abuse identified. Observations, interviews, and record review, revealed the facility had monitored and was continuing to monitor for abuse, with no further issues identified.

Based on review of the QAA (Quality Assessment and Assurance) manual and interview the facility failed to have documented evidence of having QAA meetings at least quarterly. Review of the Resident Census and Conditions of Residents report revealed the facility's census was 74 residents. Findings: Review of the facility's QAA committee manual revealed no documented evidence of quarterly meetings performed for the second, third and fourth quarter of 2022. During an interview on 04/12/2023 at 3:45 p.m., S1 Administrator confirmed QAA Committee meetings were not held for the second, third and fourth quarter for the year of 2022.

Based on observation, record reviews and interviews, the facility failed to ensure the resident's environment remains as free of accident hazards as is possible by not attempting new approaches after a resident sustained falls for 1 (#37) of 2 (#37 and #66) residents reviewed for falls. Findings: Review of the facility's Falls and Fall Risk policy revealed, in part: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 1. The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. Review of the record revealed the resident was admitted on [DATE]. The resident's diagnoses included, but not limited to the following: [NAME] cell carcinoma, low back pain, chronic kidney disease stage 4, hypertension, epilepsy, insomnia, diabetes, muscle weakness, congestive heart failure, hemiplegia, hemiparesis, aortocoronary bypass graft, pain, Chronic Obstructive Pulmonary Disease, atherosclerotic heart disease, sleep apnea, and transient ischemia attack. Review of the Minimum Data Set, dated dated dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. The resident required supervision with bed mobility and transfers and one person limited assistance with dressing and toilet use. The resident was occasionally incontinent of bowel and bladder. Review of the fall risk assessments dated 11/11/2022, 01/05/2023, and 03/27/23 revealed the resident was identified as high risk for falls. Review of the care plan revealed the following: falls - potential for related to weakness, decreased mobility, shortness of breath, uses wheelchair for mobility with staff assist, requires staff assist for transfers/bed mobility. Review of the interventions revealed: physical therapy/Occupational therapy as needed, physician as needed, pharmaceutical review of meds as needed, encourage to call for assist as needed, staff to assist as needed, keep bed locked and height appropriate for resident, assist resident to maintain a clutter free environment with adequate lighting, side rail to aid with bed mobility, nonskid socks or bare feet while in bed and while not wearing shoes, 11/11/2022 - slid off bed onto floor - re eval for therapy, and 01/05/2023 rolled out of bed onto floor while sleeping - wing mattress to bed. Review of the Incident and Accident Report dated 03/27/2023 at 2:15 a.m. revealed the following: resident was found on the floor between the bed and the wall, resident was laughing stating he didn't fall, he rolled off the bed. The bed was in the locked and low position, resident was flat on his back with his head on the frame of the bed, resident could not tell if he hit his head. Passive range of motion within normal limits for resident - no pain or discomfort, no visible injuries noted to resident's head, emergency medical services called for transfer to emergency room for possible head injuries. Physician and responsible party notified. Further review revealed there was no documentation of the wing mattress in use. Review of the care plan revealed there was no documentation of a new intervention following the fall on 03/27/2023. Observation on 04/12/2023 at 10:02 a.m. revealed the resident was asleep in his bed. A wing mattress was not observed. An interview on 04/12/2023 at 10:50 a.m. with S11 Certified Nursing Assistant supervisor revealed she didn't think that the resident has had a wing mattress. An interview on 04/12/2023 at 11:45 a.m. with S4 Assistant Director of Nursing (Unit Manager) confirmed the resident has not had a wing mattress. An interview with S8 LPN (Licensed Practical Nurse - Fall program nurse) on 04/12/2023 at 11:55 a.m. revealed she is responsible for updating the care plan with interventions after the falls. S8 LPN confirmed resident #37 did not receive a wing mattress following the fall on 01/05/2023 fall. S8 LPN confirmed there were no new approaches for resident #37 following the falls on 1/05/2023 and 03/27/2023. An interview with S2 DON (Director of Nursing) on 04/12/2023 at 12:45 p.m. confirmed there were no new approaches for resident #37 following the falls on 1/05/2023 and 03/27/2023.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident 1) of 3 (Residents 1, 2, 3) residents who had a peg (percutaneous gastrostomy) tube. The deficient practice resulted in an Immediate Jeopardy for Resident 1 on [DATE] when Resident 1 pulled his peg tube out and the physician was not notified. At 3:40PM, S3ADON/LPN incorrectly re-inserted the peg tube without a physician's order. Nursing staff at the facility administered the resident's feedings and medications without verification of gastric contents via the peg tube. The tube feeding and medications were instilled into the resident's peritoneal cavity. The resident developed peritonitis [MEDICAL CONDITION]. The Immediate Jeopardy began on [DATE] at 3:40PM. The Immediate Jeopardy ended for Resident 1 when he was transferred to the hospital on [DATE] at 9:35AM. The deficient practice ended for other residents on [DATE] when the facility fully implemented a corrective action plan which was completed prior to the State Agency's investigation, thus it was determined to be Past Noncompliance at the Immediate Jeopardy scope and severity. On [DATE] at 12:21PM, the Administrator was informed of the Past Noncompliance at the Immediate Jeopardy level that began on [DATE] and ended on [DATE]. Findings: Record review revealed Resident 1 was admitted in 2014 and currently had [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set) dated [DATE] revealed, in part, Section C- Brief Interview for Mental Status score of 3 indicated severe cognitive impairment, and Section G- indicated resident was totally dependent on staff for activities of daily living and required physical assistance of 2 persons. Review of re-admission orders [REDACTED]. Physician's orders dated [DATE] noted, in part, the following: nothing by mouth except ice chips, one can of [MEDICATION NAME] (tube feeding formula) bolus feeding four times daily with 150 ml (milliliters) water after feedings, all medications per peg tube, flush peg tube with 15 cc (cubic centimeters) water before medications and feedings, flush peg tube with 15 cc water after medications, and check for peg tube placement before administration of feedings, medications, and flushes (water). Review of the facility's policy titled Checking for Gastric Placement (peg tube) that was in effect on [DATE] revealed, in part, the following: 6. Gently insert small amount of air into gastric tube, while auscultating with stethoscope, 7. Gently pull back syringe for gastric content, and, 8. Push contents back into tube and remove empty syringe. On [DATE] at 9:50AM, an interview with S2RN Clinical Coordinator confirmed that the facility's policy in effect on [DATE] specified that peg tube placement should have been verified with 1) air, 2) auscultation, and 3) gastric contents. When asked what a nurse should do if all three components could not be verified, RN stated that the nurse should stop immediately and call the doctor. S2RN explained that the nurses chart placement verified X3 when all three components are met and document X2 when air and auscultation are used to verify placement. Review of Resident 1's Daily Skilled notes from re-admission on [DATE] at 4:43PM through [DATE] at 1:38PM revealed, in part, Resident 1's behavior was noted as no problem, sleep pattern was normal for resident, respirations were easy, non-labored, resident did not resist tube feeding procedure, no attempt to talk, resident nodded his head yes on [DATE] at 12:30PM when told he was about to get his milk, tolerated feedings and medications per peg tube with no problems noted. Review of the [DATE] Daily Skilled note revealed, in part: 3:30PM- S4LPN was called to the room and observed the resident's peg tube on the bed with bulb still inflated. 3:35PM- S4LPN notified S3ADON/LPN that the resident's peg tube was out. 3:40PM- S3ADON/LPN and S5LPN in resident's room, S3ADON/LPN replaced peg tube, tolerated procedure well. 4:15PM- Resident 1's wife in facility and was notified that resident had pulled tube out and it had been replaced. S4LPN checked placement X2, unable to aspirate gastric contents but when auscultated, air placement confirmed, S4LPN administered meds and feeding, no distress or discomfort noted during or after administering meds and feeding, tolerated well. Review of the Medication Administration Record [REDACTED]. 4:30PM- Resident 1's behavior was anxious, agitated, and trying to get out of bed. 9:00PM-resident on back, no apparent distress, peg tube checked for placement X2, unable to aspirate gastric content, but when auscultated with air, placement confirmed, feeding administered by S6LPN, no distress noted. [DATE] 1:00AM- Resident 1 trying to climb out of bed with abdominal binder pulled up above peg tube, abdominal binder re-applied, resident transferred from bed to geri-chair and brought resident by nurses' station for close observation. Resident sat at nurses' station for an hour and a half until calmed down enough to be placed back in bed, no signs of distress or discomfort noted. 5:00AM- S6LPN in room to administer meds and feeding, unable to aspirate gastric contents, when auscultated with air, placement was confirmed, medications administered per tube and flushed with 15 cc water. While administering feeding, resident started grabbing/pulling at tube. Told resident not to pull on tube, to let me give him his feeding, could not complete feeding. Checked for placement with auscultation, placement confirmed, then proceeded to flush tube without complications, abdominal binder re-applied, then shirt placed down over binder. Review of the Medication Administration Record [REDACTED]. 7:30AM- called to room by CNA and Resident 1 noted to have scant amount of dried blood around mouth. Resident has habit of chewing on inside of mouth. Resident would not open mouth, said naw and kept chewing on mouth. CNA assisted resident with bed bath and when CNA removed abdominal binder to bathe resident he continually tried to pull on tube and CNA had to guard his hand to finish bath and prevent the resident from pulling out tube. S4LPN explained to resident what tube was used for and importance of leaving tube in place, shakes head no and says naw, nurse asked resident if he wanted tube and he says, naw. Resident 1 was dressed in long sleeve shirt and abdominal binder in place. 9:00AM- resident's spouse at facility and told nurse resident was breathing funny. Resident 1 assessed by S4LPN to have labored breathing with mouth open and using accessory muscles, blood pressure-,[DATE], pulse-53, respirations- 32, temperature-96.7, oxygen saturation-77%, placed on oxygen by nasal cannula at 2 liters. 9:10AM- ambulance notified. 9:35AM- in route to emergency room . 10:58AM, physician notified. Record review revealed no documentation that physician was notified when Resident 1's peg tube came out on [DATE]. Review of physician's orders revealed no documentation of an order to re-insert Resident 1's peg tube after it came out on [DATE]. On [DATE] at 11:00, an interview with S2RN Clinical Coordinator confirmed that there was no documentation that the physician was notified when Resident 1's peg tube came out and there was no physician's order to replace the resident's peg tube. On [DATE] at 1:30PM, a telephone interview with Resident 1's physician confirmed that he was the primary care physician for resident 1 and was familiar with the resident. When asked if he was notified when resident 1's peg tube came out on [DATE] at the nursing home, he confirmed that he had not been notified. Physician also confirmed that he did not give an order to replace the peg tube. He added that if he would have been notified when the peg tube came out, he would have ordered for the resident to be sent to the emergency room . He stated that since the peg tube had only been in place for a few days before it came out, the resident should have come back to the hospital for admission. He stated that the resident would have been treated for [REDACTED]. He added that it was way too early for the nurses to try to replace the peg tube at the nursing home because no track had time to form to the stomach. He stated that when the peg tube came out, the stomach likely settled back down into the abdomen and when the peg tube was re-inserted by the nurse it did not go back into the stomach. He reported that by the time the resident was sent to the emergency room the following day, the facility had administered several feedings and medications through the misplaced peg tube and as a result the resident had peritonitis [MEDICAL CONDITION]. He stated that he spoke to the surgeon and they decided Resident 1 likely would not survive surgery in his present health state. He reported that the surgeon talked to the family and the decision was made for the resident to receive comfort care. On [DATE] at 1:40PM, a telephone interview with Resident 1's surgeon confirmed that he was the surgeon that placed resident 1's peg tube on [DATE]. Surgeon further confirmed that he was not informed by the facility when Resident 1's peg tube came out on [DATE]. On [DATE] at 4:30PM, a telephone interview was conducted with Resident 1's wife. She reported that the resident had lived at the nursing home for about three years. She reported that when she went to the nursing home on [DATE] the nurse told her that Resident 1's peg tube came out and they had put it back in. She stated that the doctor told her while they were at the hospital if anything happened with the peg tube, the resident would need to be seen by the doctor. Resident 1's wife added that she didn't know why she left him at the nursing home after they told her that they put the tube back in because the doctor told her if anything happened to the tube that he would need to be seen. She stated that she (referring to herself) must have been naïve. She reported that when she went to visit her husband (Resident 1) on [DATE], he was dressed and up in the wheelchair but he was panting and gasping for breath and his eyes were slits. She stated that she got the nurse and his oxygen level was in the 70s. She reported that the resident was sent to the hospital. She stated that once he got to the hospital, the doctor told her that the peg tube had been in the wrong place and his food and medicines had been going into the lining of his abdomen. She stated that the resident had peritonitis. She reported that the resident's stomach was big and when he got to the hospital it continued to swell and swell. She reported that the resident was in pain. She stated that he died two days later. On [DATE] at 10:00AM, an interview with S3ADON/LPN confirmed that she worked at the facility for about ,[DATE] years. She stated that she had been an LPN for about [AGE] years and had re-inserted many peg tubes. She stated that an LPN showed her how to put one in about ,[DATE] years after she started nursing, around 1987 or 1988. She couldn't remember if she had ever re-inserted a peg tube that had been recently surgically inserted as Resident 1's had five days earlier on [DATE]. She reported that she had not received training or an in-service on peg tube re-insertion in the past ,[DATE] years since she's been employed at this facility. She reported that on [DATE] she was informed that Resident 1's peg tube had come out and S4LPN and S5LPN couldn't get it back in. She reported that she went to the resident's room and everything was set up and the supplies were out to re-insert the peg tube. S3ADON/LPN reported that S5LPN put her hands on the resident's stomach to stabilize it and she put gel on the peg tube and inserted it. S3ADON/LPN reported that the peg tube slipped right in with no resistance. She added that all three nurses verified placement with auscultation. When asked, LPN confirmed that they did not get any gastric contents to verify placement of the peg tube and added that it was time for the resident's feeding. S3ADON/LPN reported that she was not sure if the resident's nurse had notified the doctor that the peg tube was out or if the nurse had gotten a physician's order to re-insert the peg tube. On [DATE] at 10:45AM, an interview with S5LPN confirmed that she had worked at the facility off and on for about seven years. She reported that she is full-time now as an MDS nurse. She stated that she works the floor at times and takes patients when she is needed. She stated that she has been an LPN for about [AGE] years. When asked if she had ever replaced a peg tube on a resident, she reported that she had replaced quite a few. She reported that she had never replaced one on a new peg tube site. S5LPN reported that on [DATE], S4LPN came and got her when Resident 1's peg tube came out. S5LPN reported that she looked at the site and wasn't comfortable replacing the peg tube because the hole looked so small. She stated that she went and got S3ADON/LPN. She reported that she observed S3ADON/LPN insert the peg tube and verify placement by auscultation. She reported that she also auscultated air for verification of placement. When asked, S5LPN confirmed that no one attempted to aspirate gastric contents while she was in the room and she left out of the room after that. S5LPN reported that she didn't know if the physician was notified that the tube came out or if a physician's order to replace the peg tube was obtained. On [DATE] at 11:45AM, an interview with S4LPN confirmed that she was the nurse taking care of Resident 1 on [DATE]. She reported that she normally takes care of Resident 1 every day that she works. S4LPN reported that she has changed out 3 or 4 peg tubes since she started working at the facility. She reported that the DON (Director of Nurses) taught her one-on-one how to replace a peg tube. She confirmed that she had not really had an in-service other than the DON showing her how to do it. S4LPN reported on [DATE] she went into Resident 1's room and his peg tube was out. S4LPN reported that she went and got the supplies to replace it. When asked if she informed Resident 1's physician that the peg tube was out and obtained an order to re-insert the peg tube before replacing it, S4LPN confirmed that she did not attempt to notify the doctor nor did she get a physician's order to replace the peg tube. She reported that she got the supplies and attempted to re-insert the peg tube but the hole was so small that she was not comfortable pushing the tube through the skin. She stated that she got S5LPN who attempted to put the peg tube back in. S4LPN stated that she left out of the room to give another resident a pain pill and when she got back to the room, the peg tube had been re-inserted. S4LPN confirmed that she observed S3ADON/LPN check placement by auscultation, S5LPN checked placement by auscultation and she, referring to herself, checked placement by auscultation. S4LPN stated that none of the nurses were able to aspirate gastric contents. S4LPN reported that shortly after the tube was replaced, she gave the Resident 1 his afternoon medications and a can of [MEDICATION NAME] feeding by peg tube. S4LPN confirmed that when she attempted to aspirate gastric contents just before administering medications and feeding on [DATE], she was not able to aspirate gastric contents. She reported that she verified placement with air and auscultation. When asked if any policies or procedures have changed since the resident was sent out to the hospital on [DATE], S4LPN reported that they can no longer just auscultate air to confirm placement of a peg tube. She stated that gastric contents must be aspirated to confirm placement. Surveyor asked what happens if gastric contents can't be aspirated, S4LPN responded that the physician must be notified and the resident would not be given medications or feeding. S4LPN added that peg tubes will no longer be replaced at the facility and that residents will be sent out for peg tube replacement. On [DATE] at 2:00PM, an interview with S1Administrator and S2RN Clinical Coordinator was conducted and they confirmed several actions were initiated as a result of the incident. The facility implemented the following: Resident 1 was transferred to the hospital by ambulance on [DATE] at 9:35AM. A Continuous Quality Improvement Corrective Action Plan dated [DATE] which noted the medical director was contacted and the policy was revised so that if a peg tubes comes out, the resident will be transferred to the ER for replacement. The facility will no long re-insert or change peg tubes. In-service education was provided to the nursing staff on [DATE] informing nursing staff of the change to the policy regarding peg tubes. In-service education dated [DATE] noted a physician's order must be obtained before any procedure is performed. In-service education dated [DATE] was titled, How to Verify a [DEVICE] is Functioning. Peg tube placement must now be confirmed with gastric content and if nurse is unable to aspirate gastric contents, the resident will be sent out of the facility to verify peg tube placement. An audit tool to monitor physician's orders for procedures was part of the corrective action plan and was ongoing at the time of the survey. The surveyor validated the corrective action plan and the date of correction was listed as [DATE] when the facility provided the last in-service education related to the deficient practice.

Based on observation, interview and record review, the facility failed to provide nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety for 1 (Resident 1) of 3 (Residents 1, 2, 3) residents. The facility failed to: 1) notify the physician when a resident's peg (percutaneous gastrostomy) tube came out, and 2) follow the policy and procedures for checking placement of the peg tube before beginning a tube feeding or administering medications via peg tube. The deficient practice resulted in an Immediate Jeopardy for Resident 1 that began on 11/15/17 at 3:40PM when Resident 1's peg tube was incorrectly re-inserted without notifying the physician. The Immediate Jeopardy ended for Resident 1 when he was transferred to the hospital on [DATE] at 9:35AM. The deficient practice ended for other residents on 11/17/17 when the facility fully implemented a corrective action plan which was completed prior to the State Agency's investigation, thus it was determined to be Past Noncompliance at the Immediate Jeopardy scope and severity. On 01/09/18 at 12:21PM, the Administrator was informed of the Past Noncompliance at the Immediate Jeopardy level that began on 11/15/17 and ended on 11/16/17. Findings: Cross refer to F693 Record review revealed Resident 1 was admitted in 2014 and currently had [DIAGNOSES REDACTED]. On 01/08/18 at 11:00AM, an interview with S2RN Clinical Coordinator confirmed that there was no documentation that the physician was notified when Resident 1's peg tube came out and there was no physician's order to replace the resident peg tube. On 01/09/18 at 10:00AM, an interview with S3ADON/LPN reported that she went to the resident's room and everything was set up and the supplies were out to re-insert the peg tube. S3ADON/LPN reported that the peg tube slipped right in with no resistance. When asked, LPN confirmed that they did not get any gastric contents to verify placement of the peg tube and added that it was time for the resident's feeding. S3ADON/LPN reported that she was not sure if the resident's nurse had notified the doctor that the peg tube was out or if the nurse had gotten a physician's order to re-insert the peg tube. On 01/10/18 at 2:00PM, an interview with S1Administrator and S2RN Clinical Coordinator was conducted and they confirmed several actions were initiated as a result of the incident. The facility implemented the following: Resident 1 was transferred to the hospital by ambulance on 11/16/17 at 9:35AM. A Continuous Quality Improvement Corrective Action Plan dated 11/16/17 which noted the medical director was contacted and the policy was revised so that if a peg tubes comes out, the resident will be transferred to the ER for replacement. The facility will no long re-insert or change peg tubes. In-service education was provided to the nursing staff on 11/16/17 informing nursing staff of the change to the policy regarding peg tubes. In-service education dated 11/16/17 noted a physician's order must be obtained before any procedure is performed. In-service education dated 11/17/17 was titled, How to Verify a [DEVICE] is Functioning. Peg tube placement must now be confirmed with gastric content and if nurse is unable to aspirate gastric contents, the resident will be sent out of the facility to verify peg tube placement. An audit tool to monitor physician's orders for procedures was part of the corrective action plan and was ongoing at the time of the survey. The surveyor validated the corrective action plan and the date of correction was listed as 11/17/17 when the facility provided the last in-service education related to the deficient practice.